Erb's Palsy (Brachial Plexus Birth Injury): Narakas Classification and Exercises
In short
Erb's palsy affects upper trunk cervical nerve roots during delivery. Learn the Narakas grading system, early passive ROM rules, and bimanual play facilitation.
In this guide (4 sections)
What Is Erb's Palsy?
Erb's palsy is an obstetric brachial plexus injury caused by excessive traction on the infant head and neck during difficult vaginal delivery (frequently associated with shoulder dystocia).
It involves the upper trunk of the brachial plexus (C5 and C6 nerve roots, occasionally involving C7). Denervation of the deltoid, supraspinatus, infraspinatus, biceps brachii, brachialis, and supinator muscles produces the classic waiter's tip resting posture: shoulder adducted and internally rotated, elbow extended, forearm pronated, and wrist flexed.
Narakas Clinical Classification and Prognosis
In 1987, Algimantas Narakas established the international classification system for neonatal brachial plexus palsy.
| Narakas Group | Nerve Roots Involved | Clinical Presentation | Spontaneous Recovery Rate | |
|---|---|---|---|---|
| Group I: Classic Erb's Palsy | C5 and C6 | Paralysis of shoulder abduction, external rotation, and elbow flexion. Normal hand function. | 80% to 90% full spontaneous recovery. | |
| Group II: Extended Erb's Palsy | C5, C6 and C7 | Shoulder and elbow paralysis combined with wrist and finger extensor paralysis (wrist drop). | 60% to 70% spontaneous recovery. | |
| Group III: Total Plexus Palsy | C5, C6, C7, C8 and T1 | Flaccid paralysis of the entire upper extremity. Sensory loss throughout arm and hand. | Poor prognosis; requires early microsurgical nerve reconstruction. | |
| Group IV: Total Plexus with Horner | C5 to T1 + Sympathetic chain | Flaccid arm paralysis with ipsilateral ptosis, miosis, and enophthalmos (Horner syndrome). | Indicates preganglionic root avulsion; zero spontaneous recovery without nerve transfer. |
Rehabilitation Protocols: Preventing Contracture
The dominant musculoskeletal complication in Erb's palsy is internal rotation and adduction contracture of the shoulder. As strong internal rotators (pectoralis major and subscapularis) overpower weak external rotators, the humeral head subluxates posteriorly, leading to glenoid retroversion and dysplasia.
- Initial Resting Period (Days 1 to 10): Pin the infant sleeve to their shirt across the chest in 90 degrees elbow flexion. Do not perform aggressive passive stretching during the acute inflammatory phase of nerve stretch injury.
- Gentle Passive ROM (After Day 10): Perform passive shoulder external rotation with the elbow tucked into the side at 90 degrees flexion. Mobilize shoulder abduction, elbow flexion, forearm supination, and wrist extension 4 to 5 times daily with every diaper change.
- Bimanual Play Facilitation: Encourage hands-to-mouth and hands-to-midline play using large textured toys, rattles, and tactile brushing to stimulate sensory re-education and prevent learned non-use of the affected limb.
- The 3-Month Biceps Recovery Milestone: Active antigravity elbow flexion recovery by 3 months of age is the critical prognostic landmark confirming excellent spontaneous neurological recovery. Failure to achieve active biceps contraction by 3 to 4 months warrants immediate referral to a paediatric brachial plexus surgical centre.
Frequently Asked Questions
Can electric stimulation be used on an infant with Erb's palsy?
Neuromuscular electrical stimulation (NMES) should be used with extreme caution and under specialized supervision. Evidence supports active play, sensory stimulation, and passive stretching as primary mainstays.
What is a trumpet sign in children with chronic Erb's palsy?
When a child lacks active shoulder external rotation, they bring their hand to their mouth by abducting the shoulder into the air like playing a trumpet. Physiotherapy focuses on retraining external rotation to eliminate this compensatory movement.
Is surgery always required if recovery is incomplete at 3 months?
Not necessarily. Children who show progressive active movement gains are followed closely until 6 to 9 months before deciding on nerve grafting or secondary tendon transfers (such as latissimus dorsi to infraspinatus transfer).
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